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Posttest

Which of the following community emergency response agencies should be involved in planning for disasters such as those involving mass exposures to cholinesterase inhibitors? (Choose ALL correct answers)

Emergency management/disaster offices

All area hospitals

The poison center

Fire departments

EMS providers

The Local Emergency Planning Committee (LEPC)

None of the above

Which of the following should be assumed to happen with incidents involving patients acutely exposed to cholinesterase inhibitors (Choose ALL correct answers)

Patients will be transported to the hospital without having been decontaminated

Chemically exposed patients will be sent to a single hospital in the community designated for chemical casualties

Since the imposition of federal laboratory standards, the normal ranges for serum and RBC cholinesterase levels are the same for each laboratory

None of the above

Supportive care is an important aspect of treatment for the cholinergic toxidrome and should be focused primarily on maintaining and improving (Choose the ONE BEST answer)

Renal function

Hepatic function

Respiratory function

CNS function

None of the above

Atropine counteracts cholinesterase inhibitor toxicity by (Choose the ONE BEST answer)

Competitively occupying muscarinic receptor sites

Competitively occupying nicotinic receptor sites

Competitively occupying nicotinic and muscarinic receptor sites

Neutralizing acetylcholine

None of the above

Which of the following is/are the best end-points against which to titrate the dose of atropine in acute cholinesterase poisoning? (Choose the ONEBEST answer)

Pupillary dilation

Pupillary constriction

Clinically significant reduction of bronchorrhea and bronchoconstriction, (as reflected by level of oxygenation and ease of ventilation)

Development of heart rate of between 100-150/min

Return of consciousness

Return of muscle strength

all of the above

None of the above

In order of preference, the best routes of atropine administration are: (Choose the ONE BEST answer)

Intramuscular is better than Intravenous which is better than Autoinjector

Intravenous is better than Autoinjector which is better than Intramuscular

Autoinjector is better than Intravenous which is better than Intramuscular

Intravenous is better than Intramuscular which is better than Autoinjector

Intravenous is best; Intramuscular and Autoinjector are equally good

None of the above

Which type of cholinesterase toxicity can require the highest doses of atropine? (Choose the ONE BEST answer)

Inhalation of nerve agent

Dermal exposure to organophosphorus agents

Suicidal ingestion of organophosphorus agents

Ingestion of carbamates

Which of the following are true about 2-PAM? (Choose ALL correct answers)

It should never be used in carbamate poisoning

It works by attaching to the cholinesterase inhibitor bound to cholinesterase, attaching to and removing the inhibitor

It reduces the effectiveness of atropine

It is ineffective after aging occurs

None of the above

Which of the following are reasons for treatment failure with 2-PAM? (Choose ALL correct answers)

Inadequate dose

Co-administration of atropine

Redistribution of cholinesterase inhibitor from fat tissue

Aging has already occurred

None of the above

Which of the following lead to delayed aging, and therefore prolongation of the time course when 2-PAM is still effective? (Choose ALL correct answers)

Co-administration of atropine

Poisoning from fat-soluble organophosphorus compounds

Dermal exposure

Poisoning with chemicals that must be metabolically converted before they possess cholinesterase inhibiting properties

None of the above

Which of the following is true about seizures resulting from cholinesterase inhibitors? (Choose ALL correct answers)

They are more common in adults than in children

Although diazepam is effective in controlling seizures, it has not been shown to improve clinical outcome

Diazepam should not be used unless seizures occur

CNS damage from cholinesterase inhibitors is due to a direct toxic effect, not seizure activity

None of the above

Which of the following are currently recommended in the routine treatment of poisoning?

Syrup of ipecac

Gastric lavage

Cathartics

Activated charcoal

None of the above

Which of the following is true regarding the intermediate syndrome? (Choose ALL correct answers)

It most commonly occurs after nerve agent poisoning

If good supportive care has been given and there is no hypoxic damage, the condition usually resolves spontaneously

Atropine is indicated if muscarinic signs are present

Delayed, but sudden-onset of respiratory weakness or paralysis may occur, leading to respiratory failure

None of the above

Which of the following are true about Organophosphate-induced delayed neuropathy (OPIDN)? (Choose ALL correct answers)

It is caused by a molecular alteration of nicotinic receptors at the neuromuscular junction of distal skeletal muscle groups

Pain is not a characteristic symptom

If there has not been any hypoxic damage, and good supportive care has been given, full recovery is the rule

Early and adequate doses of 2-PAM and atropine have been shown to prevent this condition

None of the above

Which of the following are true about Organophosphorus ester-induced neurotoxity (OPICN) (Choose ALL correct answers)

It is a set of long-term, persistent neuropsychiatric signs and symptoms

No specific treatment has been identified

Studies carried out to assess whether the condition can occur after asymptomatic exposures to cholinesterase inhibitors have suffered from methodological problems

It occurs when cholinesterase inhibitors trigger a permanent defect in neurotarget esterase

None of the above

Which of the following are true about cholinesterase inhibitors? (Choose ALL correct answers)

Chronic, asymptomatic exposure to cholinesterase inhibitors is associated with an increased risk of chronic lymphocytic leukemia

Neural tube defects have been associated with symptomatic exposures during the first trimester of pregnancy

The available evidence does not explain the myriad of symptoms of Gulf War Illness on the basis of exposure to cholinesterase inhibitors

The Wenger-Herzold study demonstrated clinically significant long-term decrements in immunity in those with long-term exposure to organophosphorus compounds, but not carbamates

None of the above

The most characteristic early finding in intermediate syndrome is: (Choose the ONE BESTanswer)

Loss of sensation in distal extremities

Inability of the patient to lift his/her head off the pillow

Muscle fasciculations

Profound salivation (liters per day)

None of the above

Muscarinic receptors are found in: (Choose ALL correct answers)

Skeletal muscle

Smooth muscle

Exocrine glands

Sweat glands

None of the above

Which of the following are true about the central nervous system effects of cholinesterase inhibitors (Choose the ONE BEST answer)

The pathology can be explained on the basis of increased muscarinic, as opposed to nicotinic, receptor activity

The pathology can be explained on the basis of increased nicotinic, as opposed to muscarinic, receptor activity

The pathology is poorly understood but involves both nicotinic and muscarinic receptors

None of the above

Which of the following central nervous system signs and symptoms have been reported in cases of cholinesterase inhibitor poisoning? (Choose ALL correct answers)

Anxiety

Emotional lability

Convulsions

Excess dreaming

None of the above

Which of the following questions on an exposure history are appropriate for the physician to ask in a patient suffering from signs and symptoms suggestive of cholinesterase inhibitor poisoning? Choose ALL correct answers

What are your hobbies?

Do you cook with wild mushrooms?

Does anyone at home have similar signs or symptoms?

Do you handle venomous snakes?

None of the above

Cholinesterase inhibitors block the ability of acetylcholinesterase to break down acetylcholine by? (choose the ONE best answer)

Occupying the binding site on cholinesterase to which the acetylcholine would attach

Preventing the release of acetylcholine from its attachment on cholinesterase

Attaching to acetylcholine which prevents its attachment to cholinesterase

None of the above

What causes the cholinergic toxidrome? (Choose the ONE best answer)

An excess of acetylcholine

A deficiency of acetylcholine

An excess of acetylcholinesterase

None of the above

Where are cholinergic receptors are found? (Choose ALL correct answers)

At the neuromuscular junction

In the central nervous system

In the sympathetic, peripheral nervous system

In the parasympathetic, peripheral nervous system

None of the above

Nicotinic and muscarinic receptors differ in which the following ways (Choose ALL correct answers)

They have different functions

They have different mechanism by which they trigger signal transmission

They may exist at different anatomical locations

None of the above

Why do excessive levels of acetylcholine (“The cholinergic toxidrome”) cause different signs and symptoms, depending on whether the nicotinic or muscarinic receptors are involved? (Choose ALL correct answers)

Because some nicotinic and muscarinic receptors are located in and affect different anatomic structures

Because nicotinic and muscarinic receptors are triggered by different neurotransmitters

Because nicotinic and muscarinic receptors have different mechanisms of action

None of the above

Factors that account for variation in the clinical presentation of cholinesterase toxicity include: (Choose ALL correct answers)

Route of exposure

The balance of nicotinic and muscarinic effects on the sympathetic and parasympathetic nervous system

Age of the patient

The specific cholinesterase-inhibiting chemical

None of the above

Which of the following are major factors leading to respiratory failure in cases of cholinesterase inhibitor poisoning? (Choose ALL correct answers)

Bronchodilation

Central respiratory depression

Weakness or paralysis of the respiratory muscles

Excessive respiratory tract secretions

None of the above

Which of the following statements are true regarding serum or red blood cell cholinesterase levels? (Choose ALL correct answers)

The use of these tests helps to avoid serious errors in emergency treatment

With current technology, interindividual variation in results, is no longer a significant problem

While percentage of inhibition in the same person may be different in different laboratories, the absolute cholinesterase values are usually the same

None of the above

Which of the following statements are true about the laboratory measurement of cholinesterase inhibitors themselves or their metabolites? (Choose ALL correct answers)

Each test can measure only one chemical, so it is only useful if you know the specific chemical to which the patient was exposed

The results are not usually available in time to guide emergency treatment

The test results are usually very accurate

None of the above

Which of the following statements is true about the patient with exposure to cholinesterase inhibitors? (Choose ALL correct answers)

If the patient has only been exposed to cholinesterase inhibitor vapor, there is no risk of secondary exposure

If the patient has ingested a cholinesterase inhibitor, others can be exposed if the patient vomits

More important than which decontamination fluid is used is how rapidly decontamination is initiated

Water and soapy water are very effective decontamination fluids

None of the above

If a hospital receives a patient with cholinesterase inhibitor toxicity and there is the potential that others were also exposed at the scene, which of the following should be notified (Choose ALL correct answers)

All other area hospitals

The local fire department

The poison center

Area EMS providers

None of the above

Relevant Content

To review content relevant to the posttest questions, see:

Question

Location of Relevant Content

1

Community preparedness

2

Community preparedness

3

What type of pathology do cholinesterase inhibitors cause?

4

What type of pathology do cholinesterase inhibitors cause?

5

Nicotine acetylcholine receptors

6

Nicotine acetylcholine receptors

7

Nicotine acetylcholine receptors

8

Muscarinic acetylcholine receptors

9

What is the cholinergic toxidrome?

10

Effects on routine laboratory tests

11

Differential diagnosis

12

Signs and symptoms: differences in pediatric cases

13

Who is at risk for exposure? The exposure history

14

Who is at risk for exposure? The exposure history

15

Effects on routine laboratory tests

16

Management strategy 2: Supportive care

17

Management strategy 3: Medications - Atropine

18

Management strategy 3: Medications

19

Management strategy 3: Medications

20

Management strategy 3: Medications

21

Management strategy 3: Medications – 2-PAM

22

Management strategy 3: Medications

23

Management strategy 3: Medications

24

Management strategy 3: Medications - Diazepam

25

Syrup of ipecac, gastric lavage, cathartics, and activated charcoal

26

The intermediate syndrome

27

Organophosphate-induced delayed neuropathy (OPIDN)

28

Organophosphorus ester-induced chronic neurotoxicity (OPICN)

29

Other issues related to cholinesterase inhibitor toxicity

30

The intermediate syndrome

31

Muscarinic acetylcholine receptors

32

Clinical findings are due to a mixture of nicotinic and muscarinic effects

33

Clinical findings are due to a mixture of nicotinic and muscarinic effects

34

Who is at risk for exposure? The exposure history

35

What are cholinesterase inhibitors?

36

The cholinergic toxidrome: What is the cholinergic toxidrome?

37

The cholinergic toxidrome: What is the cholinergic toxidrome?

38

The cholinergic toxidrome: What is the cholinergic toxidrome?

39

The cholinergic toxidrome: What is the cholinergic toxidrome?

40

The cholinergic toxidrome: Clinical findings in cholinesterase inhibitor toxicity are due to a mixture of nicotinic and muscarinic effects.

The cholinergic toxidrome: Signs and Symptoms: differences in pediatric cases